Chapter 4   Applying for IHSS and the Self-Assessment


When should I apply for IHSS?

If you are moving into a new home, apply on the first day you are in your own home, or as soon as you know where you will be living.  Otherwise, apply as soon as there is a need for services provided by IHSS.  If you are not already living in your own home, start preparing for the IHSS application when you first decide to move into your own home.


Because receipt of or eligibility for SSI/SSP is often essential to receiving IHSS without a share of cost, now is the time to apply for SSI/SSP if you are not already receiving it.  However, if it is more important for you to receive IHSS quickly, apply first for Medi-Cal with your local County Welfare Office.  You have a right to a Medi-Cal decision within 90 days but the time limit is often exceeded.  If you apply for SSI at the same time you applied for Medi-Cal, the state will not develop the Medi-Cal case but rather will wait for the SSI determination to be made.  If the SSI application is denied, the State will automatically deny the Medi-Cal application because at that point the State is prohibited from making a disability determination.


Can I apply for IHSS if I am transitioning from a facility to my home?

Yes, County IHSS workers MUST complete an assessment while you are still in a hospital or skilled nursing facility.  Otherwise eligible applicants, currently institutionalized, who wish to live in their own homes and who are capable of safely doing so if IHSS is provided, shall upon application receive IHSS based on a needs assessment. MPP 30-755.12


Service delivery will start upon your return home, except that heavy cleaning may be authorized and used in advance to prepare for your return home.


The Department of Social Services issued an All County Letter reminding county welfare departments of their responsibility to conduct assessments of applicants ready for discharge from medical facilities and non-medical out-of-home placements.  (ACL 02-68.)  This means that the person with a disability and the provider will know from the first day home that the provider will be paid for the services authorized.


If the county says it cannot assess you or take your application while you are in a facility, a fair hearing should be requested.  We also believe that if the county refuses to follow the IHSS regulations to assist an individual with a disability move from an institution to the home, then the county violates the Americans with Disabilities Act.  You may file a civil rights complaint with your county welfare department.  Call a main or administrative office telephone number and say you want to file a civil rights complaint. Or you may file an ADA complaint by a letter to:


Coordination and Review Section
Civil Rights Division
U.S. Department of Justice
P.O. Box 66118
Washington, D.C. 20035-6118


How do I Apply?

To apply for IHSS, complete an application and submit it to the local county welfare office.  To find your local office, look for the closest county welfare office listed under the County Government Section in the telephone book.  An application form may be obtained online at:


The application may be done in writing or by telephone either by the individual or through another person on his or her behalf.  If done by telephone, a county social services staff member may be given authorization to sign the application.  Be sure to state that you are making an application for IHSS and document the date, person you spoke to, etc., in case follow-up is needed.  The county is required to accept an application once they are told the purpose of the call or contact. MPP 30-009.22.


The following information is needed when making the initial call:


(1)   Full name of the individual

(2)   Sex

(3)   Social Security Number.  If the person is an alien with no social security number, see the Eligibility Section

(4)   Telephone number

(5)   Address where the person is living or will be living.  This must be the home where the person will receive services

(6)   Date the individual moved in or plans to move in

(7)   Date of birth

(8)   Age

(9)   Ethnicity MPP 30-759.1

(10)         Primary language MPP 30-759.1

(11)         Spouse's name (if married)

(12)         Spouse’s social security number

(13)         The name and relationship of any other person that will live in

the home[8].

(14)         Whether others living in the home will apply for or are already

receiving IHSS.

(15)         Medical insurance information, Medi-Cal number or other

insurance number.


And confirmation of:


(1)   The individual receiving SSI/SSP; or

(2)   Eligibility for SSI/SSP, but not receiving SSI/SSP; or

(3)   Meeting SSI/SSP eligibility except for excess income.


The county IHSS worker may ask to see confirmation at the time of the home visit.  Confirmation may be established by a current SSI/SSP Notice of Determination; a current SSI/SSP benefit check; a current Medi-Cal card; or by IHSS staff verification with the Social Security District Office, or Medi-Cal Eligibility Data System or State Data Exchange screens.  MPP 30-755.22


Confirmation of disability and income may be required along with other information.  Regional Center case file information may meet some of these requirements.  If SSI/SSP has been applied for, some of that information may be used. MPP 30-755.26


Once the application is filed, a home visit will be scheduled for the assessment.


How Long will the Application Process Take?

The application must be processed within 30 days following the application. This includes eligibility determination, the needs assessment and the notice of action.  An exception to the 30-day requirement may be made when a disability determination has not been received within the 30-day period, or the person has not moved into his or her own home. MPP 30-759.2


There have been reports of counties delaying the application process beyond 30 days with no exceptions being present.  Some of the delays reported allege that certain counties are claiming that the initial phone call is not part of the application process and that there is a waiting list backlogged for months to apply for IHSS.  If you have attempted to apply for IHSS and were told something along these lines by your county, please contact DISABILITY RIGHTS CALIFORNIAas we are interested in hearing from you regarding this matter.


Can I Receive Emergency Services?

Emergency services may be authorized to aged, blind or disabled persons prior to completion of a needs assessment pending a final determination of eligibility if the applicant’s needs warrant immediate provision of services.  Please refer to the Presumptive Eligibility section in Chapter 3 to see if you would qualify for emergency services.  MPP 30-759.8


I am Currently Receiving IHSS.  What Will Happen if I Move To Another County?

When an IHSS recipient moves from one county to another, the County Welfare/Social Services Office of each county is responsible for transfer of the case to the new county.  It is important to notify the local IHSS office before the move when moving to a different county so the intercounty transfer process can start.  There should be no break in funding during this period. MPP 30-701(i); MPP 30-759.9


                General Self-Assessment Documentation Principles


A. The assessment

When you first apply for IHSS, at least once per year, and any time you request it, you will have a county assessment. The county worker will come to your home and determine which IHSS services you are eligible for and how many hours you will receive per month. The county must do the assessment within 30 days of your request.

1. How to Measure IHSS Need

a.         Statutory and Regulatory Standard

The general standard for measuring individual need for IHSS services (assuming the person with a disability is unable to perform the needed services because of his or her disability)[9] is set out in Welfare and Institutions Code Section 12300.  The person with a disability is entitled to receive the services needed to enable him or her (1) to remain safely in his or her own home or in the abode of his or her own choosing, and/or (2) to establish and maintain an independent living arrangement.  The time that will be authorized is based on the time it takes your provider to do the tasks authorized.  No time will be authorized for services that are solely for the "comfort" of the IHSS recipient.  The maximum number of hours is 283 per month.

b.         State Time-for-Task Guidelines

There are certain state “time-for-task" guidelines predating the recent changes in IHSS that apply to domestic services and some related services:


i.        domestic services, 6 hours a month; MPP 30-757-11(k)(1)

ii.       laundry if facilities are in the building, 1 hour per week; MPP 30-757.134(c)

iii.      laundry if you have to go outside the building, 1-1/2 hours per week; MPP 30-757.134(d)

iv.      grocery shopping, 1 hour per week; MPP 30-757.135(g)

v.       other errands, 30 minutes per week.  MPP 30-757.135(e)


Typically, these time-for-task guideline will be reduced if there is more than one person in the household.  For instance, in a family of four the disabled person's pro rata share of the domestic services would be 1.5 hours per month.


The regulations recognize that time-for-task guidelines may be used only if appropriate for meeting a recipient's individual circumstance.  Below are illustrations about when the guidelines are not appropriate because of individual circumstances.


Newly Expanded Time Per Task Guidelines and Role of Functional Assessments

New regulations effective September 1, 2006, establish guideline ranges of time that may be authorized for personal care tasks and for meal preparation and cleanup unless there is a reason for authorizing more – or less – and the reason is documented in the file.  Prior to these regulations, county IHSS social workers did a home visit and determined how many hours a person needed for meal preparation and clean-up and for personal care tasks.  Most counties used to use some sort of guidelines for determining the number of hours to authorize for meal preparation and clean up and for personal care tasks even though those guidelines were illegal.  Now the county social workers will be using the regulation guidelines and how you are ranked in the functional assessment as a guide when determining the number of hours to authorize for particular tasks.  Now if a county social worker determines you need more – or fewer – hours than those listed in the guideline range, the county social worker is instructed to reevaluate his or her assessment of time needed.  If the hours are still outside the range, the social worker must document in the case file why the consumer needs hours outside the range.


Because county IHSS social workers generally have caseloads of 300-500 consumers (depending on the county), the incentive is not to find an IHSS recipient needs more time than that provided in the guideline regulations.  It is therefore extremely important that the consumers and their providers write down in detail the care provided for at least two weeks if possible before the county IHSS social worker comes to make an initial assessment or a reassessment. 


With the diary log setting out in detail your daily care needs, you will be able to identify any task where you need more time than that provided in the guidelines and you will be prepared to explain why.  If the next visit by the county IHSS social worker is for a reassessment, review the number of hours currently authorized for particular tasks.  If the time authorized is outside the range for any task, be prepared to explain your need.  Further, some of the time authorized in a particular category may be time that should be assigned to another category.  For instance, the time for assistance to and from the bathroom should be included under ambulation but may have been included under “bowel and bladder care.”


The guideline ranges vary by how the person is ranked in terms of the functional assessment.  See DSS ACL 06-34E, Appendix B.  The guideline range is not expressed in minutes but 10ths of an hour with 30 minutes shown as .50 of an hour.  The guideline ranges cover a week so to get the daily amount allowed, divide by 7.


The existing guidelines for domestic services, laundry services, food shopping and other errands are unchanged (though regulation numbers changed) except that the task of wheelchair cleaning and battery recharging was added to “miscellaneous domestic.”


Guideline ranges were adopted for the following services:


(1)     Meal Preparation – 3.02 to 7.00, MPP 30-757.131.

(2)     Meal Cleanup – 1.17 to 3.50, MPP 30-757.132. Meal cleanup does not include general cleaning of the refrigerator, stove, oven, counters, sink which is covered under “domestic services.”

(3)     Bowel and bladder care - .58 to 8.00, MPP 30-757.14(a).  Help getting to and from the bathroom is covered under ambulation; to and from commode in same room covered under transfer; enemas, catheters, suppositories, digital stimulation, colostomy and similar tasks are covered under paramedical.

(4)     Feeding - .70 to 9.33, MPP 30-757.14(c). Cutting up or pureeing food is covered under meal preparation.

(5)     Routine bed baths - .50 to 3.50, MPP 30-757.14(d).

(6)     Bathing, oral hygiene and grooming - .50 to 5.10, MPP 30-757.14(e).

(7)     Dressing & undressing - .56 to 3.50, MPP 30-757.14(f).

(8)     Repositioning & rubbing of skin including turning in bed - .75 to 2.80, MPP 30-757.14(g). Excludes care for pressure sores (decubitii) which is covered under paramedical services.

(9)     Transfer including help going from standing, sitting, prone to another position or to or from bed, chair/stairglide/walker, couch, etc., in the same room - .50 to 3.50, MPP 30-757.14(h). Help on or off commode is covered under “bowel and bladder.”

(10)    Care of and assistance with prosthetic devices (brace, hearing aid, glasses) and assistance with self-administration of medications - .47 to 1.12, MPP 30-757.14(i).

(11)    Routine menstrual care - .28 to .80, MPP 30-757.14(j).

(12)    Ambulation including moving from place to place within home, moving or retrieving assistive devices like a walker, cane, wheelchair, assistance from front door to vehicle and from vehicle to medical appointment or alternative resource - .58 to 3.50, MPP.30-757.14(k).

DSS ACLs 06-34, 06-34E (use updated Attach. B, C, D from 06-34E).


Mental Functioning

Mental functioning is the extent to which the recipient's cognitive and emotional impairment (if any) impacts his or her functioning to perform the physical IHSS tasks.  The applicant’s mental functioning is evaluated in the functions of memory, orientation and judgment.  See Appendix B ACL 06-34E. These factors are also used to determine the need for protective supervision.



Recalling learned behaviors and information from distant and recent past.



Awareness of time, place, self, and other individuals in one’s environment.



Making decisions so as not to put self or property in danger.  Recipient demonstrates safely around stove.  Recipient has capacity to respond to changes in the environment (e.g., fire, cold, house.)  Recipient understands alternatives and risks involved and accepts consequences of decisions.


c.          Diary Log

A key part of preparing for a fair hearing or for an evaluation by the County IHSS worker is a diary log of just what is done each day and how long each task takes.  We find that people often do not realize all the tasks involved in care and the length of time the tasks take.  For instance, if there are bathroom accidents, the clean-up time (which is part of bowel and bladder care) is not just the time for cleaning, but also the time it takes to take out the cleaning supplies and put them away again.  If bodily fluids or bowel movements are involved, you need to include the extra time involved in complying with universal precautions.  Further, the time involved in certain tasks may vary from day to day.  For instance, it may take twice as long one day to dress a person with spastic quadriplegia cerebral palsy as it does the next day because of differences in limb flexibility.  The IHSS authorization will be based on an average time, so it is important to know the range of time a task may take.


2. Doing Your Own Assessment

Before the hearing, complete the IHSS worksheet in Appendix C. The worksheet, like the County assessment form, is based on a one-week period except for the entry for domestic services which is for a month.  Hours are calculated in 10ths:


 .05 =    03 minutes                   .40 =  24 minutes             .80 = 48 minutes

 .08 =    05 minutes                   .42 =  25 minutes             .83 = 50 minutes

 .10 =    06 minutes                   .45 =  27 minutes             .85 = 51 minutes

 .15 =    09 minutes                   .50 =  30 minutes             .90 = 54 minutes

 .17 =    10 minutes                   .55 =  33 minutes             .92 = 55 minutes

 .20 =    12 minutes                   .58 =  35 minutes             .95 = 57 minutes

 .25 =    15 minutes                   .60 =  36 minutes             1.00 =          60 minutes

 .30 =    18 minutes                   .65 =  39 minutes             2.00 =          120 minutes

 .33 =    20 minutes                   .70 =  42 minutes             3.00 =          180 minutes

 .35 =    21 minutes                   .75 =  45 minutes             4.00 =          240 minutes

                                                                         5.00 =300 minutes

We find it easier to do the calculations if you count by minutes and then translate the hours and minutes into tenths.  For instance, if the time assisting on and off the commode and holding while on the commode to prevent falls, plus related tasks such as hand washing, averages 6 minutes each time, and the usual frequency is 5 times a day on weekdays when away at school or at training program and 7 times a day on weekends, the weekly time would be (5 x 6 min. x 5 days) + (7 x 6 min. x 2 days) = 234 minutes = 3 hours 54 minutes = 3.9 hours.


Finally, on a separate piece of paper you need to write down the reasons why you believe you need more IHSS time.  To help you, below is a listing of "Reasons Why More IHSS Time Is Needed" that we have seen in individual cases.  Some of these reasons may apply in your case.


3. Getting Ready for the County Assessment

The County worker's purpose for the home visit is to determine what an IHSS recipient or applicant can or cannot do for himself or herself and, therefore, what services are needed and the time necessary to perform those services.  Your job is to help the County worker understand all your care problems and special care needs and what they mean in terms of time.  It is important to be frank and open.  Do not minimize your disability problems and care needs because you may end up not getting the hours you need.  Even though you may feel embarrassed doing so, it is important to explain things fully so that the County worker understands your situation.


Before the County IHSS worker arrives, we recommend that you fill in the IHSS worksheet in Appendix C with the hours you think you need.  Remember, the County is going to authorize only what you really need and will not allow extra time for "comfort" services.  An example of a comfort service is extra dusting to make things look nice. You should be prepared to explain your worksheet hours: what tasks are performed, how you determined the time each takes, what special factors need to be taken into consideration, and, if relevant, why the state time-for-task guidelines are not appropriate for your circumstances.  You may wish to make a list so that you will not forget anything.


You should be prepared to explain how you determined the hours needed, particularly if there are differences between what the County authorized before and what you believe you need now.


As part of the County's evaluation process, your treating physician will be sent a form asking for information about your capacity for self-care, your functional abilities/disabilities, and — relevant to a determination of the need for protective supervision — your mental condition.  If you need paramedical services, a paramedical form will be sent to the treating physician.  You should alert the clinic or physician's office that it is coming so that you can participate in the form completion.  Preparing for the assessment of protective supervision and paramedical services needs is discussed more thoroughly in Chapter 5.


4. Documenting Special Needs

Get documentation verifying special needs — for instance, a note from your physician explaining that you need a dust-free environment because of allergies or pulmonary/respiratory problems, a note verifying bowel and bladder problems, or a need to have bed linens changed more than twice a month.  If you need range-of-motion exercises or other physical therapy, or shots, or catheterization, or suctioning, etc., get the forms from your County IHSS worker for doctor/therapist verification of need and authorization for paramedical services.  Have your doctor fill out the Paramedical Consent form at Appendix F.


5. Getting Help

If you need help applying or completing the self-assessment, you should ask a family member, friend, or current provider to assist you if possible.  If you are a regional center consumer, you should request that the regional center assist you, or hire someone to assist you, in applying and completing the self-assessment.  Such assistance is consistent with the regional center’s obligations to provide targeted case management to help you gain access to needed services and to fulfill its requirements under the Lanterman Act in helping you to achieve your goal of living as independently as possible in your own home. 




1.       Domestic Services (see page 1 of the worksheet in Appendix B)

State regulations generally allow only 6 hours per month per household for domestic services.  When the regulations were issued, the state explained that the 6 hours per month allowance was based on receiving domestic services twice a month.

If four people live in the home, the total IHSS hours allowed for the recipient will be 1.5 hours per month.  (If a recipient’s roommate lives there only as a live-in attendant, domestic services should not be pro-rated.)  The county should pro-rate hours only for common areas of the home - the recipient’s own room and/or bathroom should be authorized separately.  If the recipient needs more time for domestic services in order to remain safely at home, the county should allow an exception to the 6 hours per month time-for-task guideline.  For instance:

a.          Allergy or pulmonary respiration problem indicates a need for a dust-free environment and a need for frequent dusting and vacuuming.

b.         Trash needs to be removed daily, or more frequently than twice a month, because of roach or other vermin problems.

c.          Because the IHSS recipient spills things, frequent cleaning is required, particularly if there are roach or vermin problems.

d.         Incontinence results in a need to spot clean floor, furniture, etc., frequently.

e.          Trash bin is located through a couple of double locked doors at the rear of the building and it takes 10 minutes to get there and back.

f.           Recipient eats in bed.  Bed must be vacuumed and remade three times a day to remove crumbs.  Bed linens must be changed more frequently because of spills.

g.          Because of recipient's incontinence/accidents, bed linen must be changed more often than twice a month (daily, three times a week, once a week, etc.)

h.          Because of recipient’s skin fragility and risk of bed sores or decubiti, sheets need to be kept smooth to prevent the development of hot spots; need to insure that nothing in the bedding rubs or irritates the skin.

i.            Because IHSS recipient drops things, more picking up is required.

j.            Since seal on refrigerator worn out, more time is needed for cleaning and defrosting refrigerator.

k.          Because IHSS recipient spends most of his/her time in bed or because of sweating, sheets need to be changed more frequently than twice a month.

l.            Building-wide roach spraying requires, on a one-time basis, that everything be removed from kitchen and shelves washed and, after spraying, returned.  (Time for this is justifiable not only for health and safety, reasons, but also as necessary for establishing and maintaining an independent living situation since failure to comply may put the recipient at risk of eviction.)

2.       Personal Care Services

Personal care services must be assessed on an individual basis.  Be sure to count the time for the entire task, from beginning to end.

a.          Bathroom is inaccessible to a wheelchair.  This means additional time is required in bathing and other personal care/grooming activities.

b.         Accidents in bathroom requiring extra clean-up in bowel and bladder care.

c.          Recipient is sensitive to pain — even combing hair is very painful.  Personal care services have to be performed slowly and carefully.

d.         Recipient eats and chews slowly and has to be coaxed or the jaw manually manipulated.  Each meal may take up to 45 minutes for feeding.

e.          Although recipient can feed self, needs attendant available to help lift things, and because of choking problems.

f.           Need to be bathed more than twice per week because of spilling, incontinence, skin problems.

g.          Skin fragile and vulnerable to hot spots which can become bedsores or decubiti; need to insure that nothing is rubbing or irritating skin such as clothing, how placed in wheelchair, etc.

h.          Need to be shampooed more than once a week due to dandruff, getting food, etc., in hair.

i.            Need for extra time for communication with IHSS provider (as for a person with cerebral palsy, who must use word and alphabet board).

j.            Susceptible to respiratory infections so hair must be dried after shampoo.

3.       Related Services

a. Extra time needed in meal preparation and/or menu planning because:

i.       Recipient needs a special diet — i.e., a diet excluding salt and sugar or requiring fresh foods;

ii.      Recipient needs to have food cut up or pureed;

iii.     IHSS recipient needs between-meal liquids and/or snacks.

iv.     Diet and eating patterns differ from rest of family so meals are prepared separately.

b.         Recipient needs two to three times as much food because of cerebral palsy with spasticity and therefore needs more time for meal preparation, menu planning and clean-up, shopping and feeding.

c.          Extra time in meal clean-up to clean table, wheelchair, and floor due to spilling.

d.         Extra time is needed for laundry because:

i.       Extra bed linen and clothing changes are necessary due to incontinence, spilling and the need to rinse before washing.

ii.      Extra time needed to comply with universal precautions when bodily fluids involved (urine, feces, blood, saliva, mucous, vomit) - i.e.: rinsing, separating from other laundry and washing separately.

iii.                Need to stay with laundry during wash and dry because of theft.

iv.               Need to put clothing through an extra rinse cycle because of skin sensitivity.

e.          Extra time is needed for shopping, errands, because of:

i.       Distance to primary market.

ii.      Need to go to market more frequently or to go to more than one place because of special diet, need for fresh food.

iii.     Frequent need to get medication because of Medi-Cal limitations on prescription size, because all medication needs cannot be met at one place.

iv.     Living in a low-income area, markets are fewer and more crowded meaning a longer wait in line.

v.      Need to use public transportation and taxis.

4.       Transportation Accompaniment

As stated above, the time involved in certain tasks may vary from day to day.  The IHSS authorization will be based on an average time, so it is important to know the range of time a task may take.  With this in mind, you will want to count your transportation time so as to factor in those times when traffic has been particularly congested on your way to necessary medical appointments and other places where alternative resources to IHSS will be provided. 


Further, if you require accompaniment in the waiting room for your medical appointments, that time should also be factored in.  IHSS will pay for transportation time to get you there and back but usually not the time while at the doctor’s or clinic.  When IHSS does not cover wait time, then IHSS should cover the transportation time for 4 trips: there and back to drop off; there and back to pick up.


Documentation Should Reflect Your Personal Schedule

Historically, time was assessed and guidelines have been based on county contract IHSS providers who do not provide services over the weekend.  Of course, you need and are entitled to receive services over the weekend regardless of what it says in the contract between the county and the attendant/homemaker chore agency.  Your self-assessment should reflect your individual schedule, including any extra time required on weekends due to a greater presence in your own home during that period.


Similarly, because the assessment is intended to cover your IHSS needs over the course of a year, you should factor in any holiday or seasonal breaks that are observed at alternative resource sites you otherwise attend which will result in more care provided to you in your home during those periods.


Documentation Should Include Alternative Resources

It is important to remember that in developing its needs assessment, the county must include IHSS-type services provided voluntarily or through other sources, including the source and amounts of those services.  MPP 30-761.273.  Therefore, you should document your self-assessment in the same way.  Such careful documentation may help to establish you as a “severely impaired” recipient, which may result in more hours and provide you with the option to elect advance payment if you so choose.



A reassessment is a review of past assessments and the current situation of the person.  It may be requested by the recipient, service provider, regional center, family member, or other entity. A reassessment will also be done if the county receives information that the situation of the person has changed.

If the person's situation has changed or shows a need for more or fewer IHSS services than authorized and he or she is not receiving the maximum IHSS hours (195 or 283), document the need and request a reassessment.


Once an individual has been found eligible for IHSS hours based on an assessment of his or her needs, the county has the burden of showing a change in circumstances or medical improvement which justifies a reduction in the previously assessed hours.  At a hearing to challenge the reduction, the prior determination of need would give rise to a rebuttable presumption that the claimant continued to need attendant care services, based on the County’s earlier determination.  The State through its agent County would have the burden of justifying any reduction based on changed circumstances or medical improvement.  If the hearing officer incorrectly imposes the burden of proof on the claimant, this is an effective denial of a fair hearing. Call DISABILITY RIGHTS CALIFORNIAto receive a copy of a memo describing the county’s burden.

[8] A housemate means a person who shares a living unit with a recipient. Live-in provider means a provider who is not related to the recipient and who lives in the home expressly for the purpose of providing IHSS-funded services. Do not call a live-in provider/attendant a roommate as this may cause an error in the assessment of authorized hours for some services. MPP 30-701(h)(2); 30-763.47; 30-701(l)(3).


[9] You are unable to perform the needed services if the performance causes pain.

[10] Thanks to Jennifer Pittam of C.H.O.I.C.E.S.S. for compiling many of these factors.